Original Manuscript
Why Physicians Don’t Ask: Interpersonal
and Intrapersonal Barriers to HIV
Testing—Making a Case for a
Patient-Initiated Campaign
Journal of the International
Association of Providers of AIDS Care
1–7
ª The Author(s) 2014
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/2325957414557268
jiapac.sagepub.com
Monisha Arya1,2,3, Sajani Patel4,5, Disha Kumar4,5,
Micha Yin Zheng6, Amber Bush Amspoker2,3,
Michael Anthony Kallen7, Richard Lewis Street Jr2,3,
Kasisomayajula Viswanath8, and Thomas Peter Giordano1,2,3
Abstract
In 2006, the US Centers for Disease Control and Prevention recommended HIV testing for all adolescents and adults aged 13 to
64 in health care settings with a HIV prevalence of at least 0.1%. However, 55% of US adults have never been tested and therefore
do not know their HIV status. To understand suboptimal HIV testing rates, this study sought to illuminate interpersonal and
intrapersonal physician barriers to HIV testing. One hundred and eighty physicians from health centers in Houston completed
a survey based on Cabana’s Knowledge, Attitudes and Behaviors model. One-third of the physicians faced at least 1 interpersonal
barrier to HIV testing, such as a difference in age or language. Many (41%) physicians faced at least 1 intrapersonal barrier, such as
believing their patients would be feeling uncomfortable discussing HIV. Notably, 71% of physicians would prefer their patients ask
for the test. A patient-engaging campaign may be an innovative solution to increasing HIV testing and reducing the number of
undiagnosed persons.
Keywords
HIV testing, patient–physician communication, physician barriers, patient-centered campaign
Introduction
HIV Testing in the United States
Over 1.1 million persons in the United States are infected with
HIV, and almost 1 in 6 persons are unaware of their infection.1
The HIV epidemic in the United States continues, in part,
because routine HIV testing remains suboptimal. According
to a 2014 US Centers for Disease Control and Prevention
(CDC) report, only 36% of US adults aged 18 to 64 have ever
been tested for HIV.2 There are numerous missed opportunities
for HIV testing that have negative consequences.3–5 A CDC
report found that patients diagnosed late with HIV had visited
a health care facility a median of 4 times before eventually
being tested for and diagnosed with HIV by their health care
provider.6 Even when patients have clinical conditions suggestive of HIV, 1 study found that 82% of these patients never
received a recommendation for HIV testing.4 Thus, many
patients are diagnosed with HIV late in their disease progression, and nearly a third of people diagnosed with HIV receive
a diagnosis of AIDS within 1 year following their HIV diagnosis.7 Missed opportunities for HIV testing also increase the
probability of ongoing HIV transmission in the community.
Studies have found that nearly 50% of new HIV infections in
the United States are attributable to individuals who have not
been tested and are therefore unaware of their HIV-positive
status.8
HIV testing offers several benefits. Routine testing for HIV
helps find those who are HIV positive so that they may begin
1
Department of Medicine Section of Infectious Diseases, Baylor College of
Medicine, Houston, TX, USA
2
Department of Medicine Section of Health Services Research, Baylor College
of Medicine, Houston, TX, USA
3
Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael
E. Debakey VA Medical Center, Houston, TX, USA
4
School of Social Sciences, Rice University, Houston, TX, USA
5
Wiess School of Natural Sciences, Rice University, Houston, TX, USA
6
University of California, Berkeley, School of Public Health, CA, USA
7
Department of Medical Social Sciences, Northwestern University Feinberg
School of Medicine, Chicago, IL, USA
8
Department of Social and Behavioral Science, Harvard School of Public
Health, Boston, MA, USA
Corresponding Author:
Sajani Patel, 6330 Main Street c/o Will Rice College, Houston, TX 77005, USA.
Email: [email protected]
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2
Journal of the International Association of Providers of AIDS Care
antiretroviral therapy to decrease their viral load, the main biological predictor of HIV transmission.9 In addition, persons
aware of their HIV-positive status engage in fewer risky behaviors leading to a reduction in HIV transmission to others.9,10
In 2006, the CDC recommended routine HIV testing for all
adults in high HIV prevalence areas in order to reduce late
diagnoses and prevent the ongoing spread of HIV in the United
States.11 However, according to the December 2013 CDC
National HIV Prevention Progress Report, although achievements have been made in increasing the percentage of people
living with HIV who have been diagnosed as HIV positive,
from 80.9% in 2006 to 86.2% in 2010, there remains a substantial group of HIV-positive individuals unaware of their status.12
The December 2013 CDC Report noted that although the
reduction in late-stage HIV diagnoses is on track, greater
decreases are necessary.12 Routine HIV testing and more frequent physician-initiated HIV testing will help to improve HIV
testing rates.
Methods
Study Location
Houston, the fourth most populous city in the United States,22
is a high HIV prevalence area.22,23 Approximately 95% of the
HIV/AIDS cases in the Houston metropolitan area are in Harris
County.23 In 2011, there were 30 new HIV diagnoses per 100
000 population in Harris County,23 compared to 15.8 new HIV
diagnoses per 100 000 population in the overall United States.7
This study took place from January to March 2013 with primary care physicians from 19 publicly funded community
health centers in Harris County, Houston, Texas. These community health centers have over 1 million patient visits per year
and care for predominantly Hispanic (57.4%) and African
American (26.3%) patient populations—the populations most
affected by the HIV epidemic in the United States.24
Study Design
Physicians Are Missing Opportunities for HIV Testing
Despite the national recommendations for routine HIV testing
and the known benefits of such testing, physicians are still not
routinely testing their patients for HIV. In a national survey of
over 1500 US adults, 72% of the respondents reported that their
physician had never brought up HIV testing in a discussion.13
Another study conducted in a high HIV prevalence city found
that 89% of physicians had never suggested HIV testing to their
patients.14 In 2013, a study found that 71% of HIV-positive
patients had at least 1 health care encounter during the year
prior to their HIV diagnosis during which their physicians
failed to test them for HIV.3
An anonymous, Web-based survey for physicians about HIV
testing was created based on constructs from the Cabana model
aimed at identifying barriers and facilitators of physicians’
adherence to guidelines.25 According to the Cabana model,
knowledge, attitudes, and behavioral skills are individual and
interacting factors that contribute to physicians’ adherence to
guidelines.25 These skills could be classified as inter- or intrapersonal factors that affect a physician’s actions. Our study
focused on the interpersonal and intrapersonal factors that prevent physicians from initiating HIV testing discussions with
their patients. Our study also collected information on physician knowledge, attitudes, and behavior on HIV testing recommendations and self-reported HIV testing behaviors.
Physician Barriers to HIV Testing
Physicians have reported a number of barriers to HIV testing,
including time,15–18 competing clinical priorities,17–19 and concerns about reimbursement.17,20 Although external barriers to
HIV testing exist, physicians may also face interpersonal and
intrapersonal barriers. Interpersonal barriers are differing characteristics, such as age, race, or language, which impede effective communication between 2 people. Intrapersonal barriers
are an individual’s predisposing, cognitive barriers to communication, such as wrong assumptions or varied perceptions21
about patient attitudes toward HIV testing. This type of barrier
is a result of personal experiences, values, personality, or education.21 To better inform interventions designed to improve
rates of physician recommendation of HIV testing for their
patients, we first need to identify specific barriers to this practice. The objectives of this study were to (1) determine whether
physicians knew and agreed with the 2006 CDC HIV testing
recommendations, (2) illuminate the interpersonal and intrapersonal barriers impeding physicians from initiating an HIV
testing discussion with their patients, and (3) explore potential
solutions to overcome physicians’ inter- and intrapersonal barriers to HIV testing.
Recruitment
To understand the HIV testing knowledge, attitudes, and behaviors of primary care physicians in Harris County’s largest publically funded health care system, purposive sampling was
utilized to recruit participants. The names, specialties, and
e-mail addresses of all primary care physicians (internal medicine, family practice, obstetrics and gynecology, and internal
medicine/pediatrics) at participating community health centers
were obtained from leadership at these sites. Physicians were
informed of the research study via e-mail, which included a
Web address to the consent cover letter and study survey. For
some community health centers, leadership sent the e-mail with
the study survey Web address to primary care physician listservs. Participants were also recruited through postcard reminders in their office mailboxes and announcements at medical
conferences. To increase the response rate, a reminder e-mail
was sent with the survey Web link. Nominal incentives of a
US$10 gift card and entry into a US$100 raffle were offered.
The Baylor College of Medicine institutional review board
approved this study.
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Arya et al
3
Measures
Physicians were asked about their knowledge, attitudes, and
behavior about HIV testing adult patients in the primary care setting. To assess knowledge, physicians were first asked ‘‘Before
this survey, I was Aware/Unaware that the CDC had issued
updated recommendations for routine HIV testing in 2006.’’ Physicians were queried about their attitudes by indicating whether
they think HIV testing should be routine for all adult patients aged
18 to 64 and were categorized as agreeing if they responded
‘‘Agree’’ or ‘‘Strongly Agree’’ or were categorized as disagreeing
if they responded ‘‘Disagree’’ or ‘‘Strongly Disagree.’’ Additionally, physician behavior was assessed by inquiring about whether
physicians test all adult patients aged 18 to 64. Furthermore, physicians also indicated the extent to which they agreed with 5 interpersonal (ie, differences in age, language, and culture, unsure how
to initiate the topic of HIV testing, and afraid that the topic of HIV
could negatively affect their patient–physician relationship) and 3
intrapersonal barriers (ie, physicians believe their patients would
be uncomfortable, offended, or would refuse the HIV test) to
HIV testing. With the exception of 3 interpersonal barriers
(ie, differences in age, language, and culture) that were rated on
a dichotomous scale, where 0 indicated that the difference was
not a barrier and 1 indicated that it was a barrier, physicians were
considered to have endorsed the existence of a barrier when they
answered agree or strongly agree to these survey items and were
considered to have not endorsed a barrier when they answered
disagree or strongly disagree. Finally, physicians were asked
about patient-centric solutions to overcome HIV testing barriers.
Data Analysis
Descriptive statistics were used to characterize study participants as well as physician knowledge, attitudes, and behavior
about HIV testing adult patients in the primary care setting. Frequency statistics were used to describe endorsement of each of
the 5 interpersonal and 3 intrapersonal barriers to HIV testing.
We then obtained (1) the number and percentage of physicians reporting at least 1 of the 5 interpersonal barriers and
(2) the number and percentage of physicians reporting at least
1 of the 3 intrapersonal barriers. Subsequently, chi-square (w2)
tests were performed to examine the associations between
whether physicians in this study test all adult patients aged
18 to 64 (yes versus no) and (1) endorse any interpersonal barriers (yes versus no) and/or (2) endorse any intrapersonal barriers (yes versus no). Finally, frequency statistics were
reported for patient-centered solutions. All analyses were conducted using SAS Statistical Software version 9.3 (SAS Institute, Cary, North Carolina).
Results
Study Participants
The survey was e-mailed to 561 primary care physicians in
community health centers in Harris County. A previous publication reported results from a subpopulation of these
physicians.26 A total of 175 physicians completed the survey
(response rate: 31.1%). Of the 173 physicians who reported
their professional status, 103 (59.5%) were trainees—interns,
residents, or fellows—and 69 (39.9%) were faculty. Of the
170 physicians who reported their specialty, 64 (37.7%) were
internal medicine, 49 (28.8%) were family practice, 36
(21.2%) were obstetrics and gynecology, and 19 (11.2%) were
internal medicine/pediatrics. Of the 171 physicians who
reported their gender, 112 (65.5%) were female. The average
age of all participants was 34.1 years (standard deviation [SD]
¼ 8.5 years). On average, participants graduated from medical school 8 years ago (SD ¼ 9.0 years, range ¼ 1-45 years).
See Table 1 for demographic characteristics.
Knowledge, Attitudes, and Behavior
A majority (n ¼ 123, 70.3%) of physicians were aware that the
2006 CDC recommendations for HIV testing state that all adult
patients in areas of high undiagnosed HIV prevalence should be
routinely tested. Furthermore, 153 (87.4%) physicians think
that HIV testing should be routine for all adult patients aged
18 to 64. However, only 119 (68.0%) of physicians actually
routinely test all adults for HIV.
Interpersonal Barriers
Physicians reported multiple interpersonal barriers that prevent
them from offering HIV tests to their patients (see Table 2).
Overall, nearly one-third of physicians (n ¼ 52, 29.7%) said
at least 1 interpersonal barrier prevented them from offering
an HIV test. These barriers include differences between them
and their patients in age (n ¼ 14, 8.0%), language (n ¼ 15,
8.6%), and culture (n ¼ 24, 13.7%), as well as being unsure
of how to initiate the topic of HIV testing with their patients
(n ¼ 14, 8.0%) and being afraid that the topic of HIV could
negatively affect their patient–physician relationship (n ¼ 15,
8.6%).
Reporting at least 1 of these 5 interpersonal barriers was significantly associated with whether one tested all adult patients
(w2(1) ¼ 5.09, P ¼ .02). Those who reported at least one of
these barriers were significantly less likely to report testing all
adult patients for HIV relative to those who did not report any
interpersonal barriers. Specifically, 29 (55.8%) physicians who
reported at least one of these barriers tested all their patients,
whereas 90 (73.2%) physicians who reported no interpersonal
barriers tested all their patients.
Intrapersonal Barriers
Physician misconceptions about their patients’ attitudes
toward HIV testing could also be a barrier to testing (see
Table 3). Many (n ¼ 62, 35.4%) physicians believed their
patients are uncomfortable discussing HIV, some (n ¼ 29,
16.6%) felt their patients would be offended if offered an HIV
test, and a few (n ¼ 12, 6.9%) physicians thought that their
patients would refuse an HIV test. Many (n ¼ 72, 41.1%)
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4
Journal of the International Association of Providers of AIDS Care
physicians said at least 1 intrapersonal barrier prevented them
from offering an HIV test.
Reporting at least 1 of these 3 intrapersonal barriers was
not significantly associated with whether one tested all adult
patients (w2(1) ¼ 1.70, P ¼ .19). Those who reported at least
one of these barriers were statistically just as likely to report
testing all adult patients (n ¼ 45, 62.5%) as those who did not
report any barriers (n ¼ 74, 71.8%).
Patient-Centered Solutions
Although 60 (34.3%) physicians reported that information
showing patients are receptive to HIV testing would help
them offer an HIV test to their patients, more than twothirds (n ¼ 124, 70.9%) of physicians felt that they would
be more likely to test their patients for HIV if their patients
asked them for the test.
Discussion
This study, conducted during the routine HIV testing era in the
nation’s fifth largest publicly funded health care system,27
found that physicians are generally aware of and agree with the
2006 CDC recommendations for routine HIV testing. Previous
studies have found numerous barriers that hinder physicians
from recommending HIV testing routinely to all of their
patients.15–20 The most notable barriers are time and competing
clinical priorities. Our study has illuminated several interpersonal and intrapersonal barriers and misconceptions that may be
impeding physicians from discussing HIV testing with their
patients and ultimately recommending HIV testing. Moreover,
our study found that at least one-third of physicians face interpersonal or intrapersonal barriers to recommending HIV testing. We found that many physicians fail to offer an HIV test
because they believe their patients would be uncomfortable,
offended, or refuse the test. However, other research indicates
patients may not feel this way. For example, a recent study
reported that patients likely would not be offended or uncomfortable if their physician offered the test, given that these
patients reported ‘‘expecting’’ and ‘‘wanting’’ HIV testing to
be initiated by their physicians.28 Our findings highlight physician cognitive-affective influences (eg, attitudes, perceptions,
goals, and motivations) as key factors in the patient–physician
relationship. Consistent with the Cabana model, physicians’
perceptions of and assumptions about their patients affect their
goals for the encounter and the communicative approach to
managing the encounter.25 For example, a physician may feel
that offering an HIV test to a middle-aged female married for
20 years might be offensive to her. As another example, a physician may consider offering an HIV test to a homosexual
patient but may be uncomfortable talking about it and thus not
bring it up.
To overcome physician interpersonal and intrapersonal HIV
testing barriers, a pioneering intervention to improve HIV testing in health care settings may be a patient-initiated approach.
Our study found that some primary care physicians are unsure
of how to initiate the topic of HIV testing with their patients
and that 70% of the respondents would be more likely to offer
the HIV test if their patients asked them for it. Other studies
have also found that physicians want their patients to ask for
the HIV test.29 Although there is evidence supporting the fact
that patients actually want their physicians to test them for
HIV,30,31 our study found that some physicians are afraid
that the topic of HIV would negatively affect their patient–
physician relationship. Since physicians are not routinely offering HIV testing and face inter- and intrapersonal barriers,
campaigns that will cue patients to engage their physicians in
a discussion about HIV testing could be particularly effective.
The quality of physician–patient communication has been
associated with (1) greater patient understanding of his or her
health and (2) better health outcomes.32 Studies have also
found that patients who are more engaged and actively
involved in their own health have better communication with
their physician and receive more personalized care.33 Because
most patients want to be active participants during the health
care encounter,34 they would potentially be receptive to a cue
to initiate health discussions with their doctors which in turn
should increase HIV testing rates. Notably, one-third of respondents in a national survey reported wanting strategies to help
discuss HIV with their physician, with only 46% having ever
had a discussion about HIV with their physician.35 Unfortunately, racial and ethnic minority populations face greater HIV
disease burdens yet have the most likely to have undiagnosed
HIV in the United States.36 Furthermore, racial and ethnic
minorities ask their physicians the fewest questions, highlighting the need for targeted campaigns for these patient
populations.37
With the 2013 release of the US Preventive Services Task
Force Grade A recommendation for routine HIV testing of all
persons aged 15 to 65, novel strategies are needed to encourage
more widespread HIV testing in health care settings.38 Key
objectives of Healthy People 2020 include increasing the proportion of people who have been tested for HIV, improving
patient–physician communication, and increasing the amount
of patient involvement when making health decisions.39 The
‘‘push–pull’’ capacity model could be the means by which
patient activation might work to increase physician recommendations.40 This model offers a framework to guide a novel solution to improve HIV testing that is patient initiated, fosters
patient–physician communication and thereby helps overcome
documented physician HIV testing barriers. This model could
be used to create a campaign that prompts, or ‘‘pushes,’’
patients to engage, or ‘‘pull,’’ their physicians into a discussion
about the HIV test.
This study is subject to several limitations. First, the results
may not be generalizable due to (1) the relatively small sample
size and (2) the fact that physicians were all from a single health
care system. Second, this study took place in a large, publicly
funded health care system in a city with a high HIV prevalence;
thus, the results may not be applicable to other health care settings. Third, the study participants were primary care physicians,
many of whom were trainees, and may not share the same
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Arya et al
5
Table 1. Demographics and Specialties of Study Participants.a
Demographic Characteristic
n
Gender (n ¼ 171)
Male
Female
Race (n ¼ 165)
Asian
American Indian/Alaskan Native
Black/African American
Native Hawaiian or other Pacific Islander
White
Other
Professional status (n ¼ 173)
Intern
Resident
Fellow
Medical school faculty
Directly employed staff physician
Specialties (n ¼ 165)
Family practice
Internal medicine
Internal medicine/pediatrics
Ob/gyn
Pediatrics
Other
Table 2. Interpersonal Barriers to HIV Testing.a
%
Reporting
Reporting
this Barrier, n this Barrier, %
Survey Item
59
112
34.5
65.5
59
1
23
1
75
6
35.8
0.6
13.9
0.6
45.5
3.6
25
77
1
69
1
14.5
44.5
0.6
39.9
0.6
47
64
19
33
1
1
28.5
38.8
11.5
20.0
0.6
0.6
a
N ¼ 175.
perspectives as other physicians. Finally, selection bias may
have influenced results as participants had to opt-into taking the
survey. Despite these limitations, to our knowledge, this is the
first study to focus on cognitive-affective influences on the
patient–physician relationship among patients and physicians
in a large, publically funded health care institution.
Differences in age between physician
and his or her patient
Differences in language between
physician and his or her patient
Differences in culture between
physician and his or her patient
Unsure how to initiate the topic of HIV
testing with his or her patient
Afraid that the topic of HIV could
negatively affect their patient–
physician relationship
14
8.0
15
8.6
24
13.7
14
8.0
15
8.6
a
Number (%) reporting at least 1 interpersonal barrier: 52 (29.7%).
Table 3. Intrapersonal Barriers to HIV Testing.a
Survey Item
Think their patients are
uncomfortable discussing HIV
Think their patients would be
offended if offered an HIV test
Think their patients would refuse the
HIV test
Reporting this Reporting this
Barrier, n
Barrier, %
62
35.4
29
16.6
12
6.9
a
Number (%) reporting at least 1 intrapersonal barrier: 72 (41.1%).
Affairs. A previous publication in this Journal reported results from a
subpopulation of this study population.
Declaration of Conflicting Interests
Conclusion
Physicians face numerous interpersonal and intrapersonal barriers to offering HIV testing; further research is needed to elucidate innovative solutions to overcoming these barriers.
Physicians want their patients to be more proactive in asking
for an HIV test. We hypothesize that a patient-oriented campaign could increase patient engagement in their own health,
thus reducing both inter- and intrapersonal physician barriers
to HIV testing. Improved patient–physician communication
and patient-initiated testing can lead to increased routine HIV
testing and improved health outcomes.
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
Acknowledgment
The author(s) disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: This
research was supported by a Baylor-UT Houston Center for AIDS
Research (CFAR) grant (AI036211, to Principal Investigator: Arya),
an NIH-funded program and the National Institute of Mental Health
of the National Institutes of Health under Award Number
K23MH094235 (to Principal Investigator: Arya). This work was supported in part by the Center for Innovations in Quality, Effectiveness
and Safety (#CIN 13-413) at the Michael E. DeBakey Veterans Affairs
Medical Center.
The authors would like to thank Ms Ashley Phillips for her thoughtful
comments and editorial assistance on the article.
References
Authors’ Note
The content is solely the responsibility of the authors and does not
necessarily represent the official views of the National Institutes of
Health. The views expressed in this article are those of the authors and
do not necessarily represent the views of the Department of Veterans
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